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Last year, the Royal College of General Practitioners published a report: Care planning: Improving the lives of people with long term conditions, introducing a new way for GPs and people living with a long-term condition to work together. The RCGP has now launched a programme of work to support care planning in primary care, led by their Vice Chair Professor Nigel Mathers, and Dr Sue Roberts, Chair of the Year of Care Partnerships.

We spoke to Professor Mathers to learn more about this proposed cultural shift.

What is care planning and how does it link with self management support?

The term ‘care planning’ was used as part of the Diabetes UK Year of Care project, which piloted a new way of supporting people with long-term conditions. It is an initiative closely related to self management support, which recognises that people living with a long-term condition are managing their own care most of the time, and reorients services to support them to do it better.

Care planning is a joint process in which a person and their healthcare professional work together to create a personalised package of care. It is underpinned by the principles of patient-centredness and partnership working, with the person setting their own goals and determining how they will achieve them. This approach helps put self management support into practice, as part of routine care for people with long-term conditions.

Could you give some background about long-term conditions and the problems you want to solve?

Over 15 million people in England alone have one or more long-term condition. That’s 30% of the population taking up 70% of NHS spend. These figures are projected to increase dramatically with the ageing population, so there’s an urgent need for a new system to address this.

Evidence suggests that supporting self management by planning care together can help to improve health outcomes and quality of life for patients, while also reducing the strain on healthcare resources.

What are the main aims of the RCGP’s care planning in primary care programme?

We would like to make joint care planning the norm, embedding it into NHS delivery and redesigning the service to help clinicians support people to better manage their own long-term conditions.

To do this we’ve formed a consortium of organisations who share our aims. Each will support a ‘Community of Practice’ who are trying to embed care planning, evaluating as they go. We also have an Expert Reference Group feeding back learning from the programme.

Can you explain the vision for how care planning in primary care should work?

Patients have relatively little contact with their doctors each year when compared to the time they spend managing their own condition. Planning care together enables people to look after themselves better between consultations. So, for example, a person with diabetes would use their time with a doctor to agree what objectives they’d like to work towards between consultations. The person would then put their self-care into practice, making small and manageable changes to their diet or to their level of physical activity, for example. They might also attend a blood test and receive the results before their next consultation so they could discuss them with their doctor.

Can you explain how this approach will benefit clinicians and people living with a long-term condition?

Clinicians report greater satisfaction with their work, and less stress, because they share the responsibility for care with the patient. Equally the people they support are more confident managing their own condition. With the right support in place they are also more likely to adhere to the care plan. In the long run it may mean less frequent consultations, but people could also get ongoing support from their GP through text messages or phone calls, so they can check in and ask questions.

It’s a more efficient system, but it’s not driven by budget cuts – we were pioneering this system before the cuts. It’s about improving health outcomes and achieving excellent clinical practice.

What challenges do you think you'll face in implementing the programme?

This is a cultural revolution. Doctors are brought up to feel very responsible for patients’ health, so it’s a gradual process for them to build their confidence and learn to trust their patients to take more ownership of their care. It involves negotiation and initially takes time. It’s really a different way of practising medicine.

So far, care planning has been developed for single conditions, but people often have more than one condition to manage. We want to find a holistic method that incorporates multiple conditions, so people can attend one consultation about all the conditions they have – a much more personal service. That’s the holy grail we’re working towards.

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